Domestic Abuse – an Issue for Health Care Professionals

D Ward

For too long society has condemned violence and abuse outside the home but condoned violence and abuse inside the home.

The question must now be asked – is domestic violence condoned, condemned or just ignored.

in the Accident & Emergency Department?
In the hospital clinic?
In the consulting room?
In the antenatal clinic?

What do we mean by domestic violence or domestic abuse?. We have heard a variety of definitions today. The following definition from the United Nations covers a much wider area of violence against women but not strictly domestic violence – it, however, defines the different categories of abuse:

“Any act of gender based violence that result in, or is likely to result in, physical, sexual, psychological harm or suffering to a woman including threats of such acts, coercion or arbitary deprivations of liberty, whether occurring in public or private life.”

A simpler definition for this discussion today is:

“Physical, sexual or psychological abuse of an adult woman normally by male partners or ex-partners.”

It can, however, also take place within gay and lesbian relationships. 95% of those abused are women and some sources estimate 1 in 4 women in a partnership are affected. The true figure is not known as it is hidden or under-reported by the woman herself through fear or the mistaken belief that it will not happen again

Domestic abuse, like poverty, is a serious public health issue – a serious social disease which has been ignored for too long. It has now reached epidemic proportions because of increased awareness and more encouragement to report but it is not a new disease and a veil of silence is still drawn by the woman and her family. It affects women in all walks of life and is an obstacle to their equality, development and peace. It can be contagious and be passed on from one generation to the next – father to son and mother to daughter.

It is said to be more common where there is poverty, poor housing, unemployment and substance abuse (especially alcohol), but it is no respecter of culture, class or race. It is found in both developed and developing countries – in the poor and in the rich homes—among skilled and unskilled workers – and in professional homes – doctors, ministers of religion, bankers, lawyers and teachers.

There is growing evidence to confirm that domestic abuse does have serious and long lasting consequences for the health and well being of women and their children. These consequences are also great for every nation in the world using scarce health care resources of countries and communities. In my home town of Glasgow the annual cost to the health budget is estimated at 20-30M USD.

What are the manifestations of domestic abuse?

Physical injuries	Bruising	Burns	Bites
	Choking/Strangling	Knifing	Punching
	Scalding	Scratching	Hair pulling

Abused women are 13 times more likely to have multiple injuries to neck, abdomen, chest and genitalia than non-abused women.

Sexual Abuse	Forced sex	oral/vaginal/anal	Sexual assault with objects
	Enforced prostitution	Forced tying up
	Forced into pornography	urinating on body
	Sadomasochistic practices

Psychological abuse	Criticism	Financial deprivation	Verbal abuse
	Humiliation	Degradation	Threats
	Forced to do trivial/menial	tasks	Jealousy
	Destroying personal belongings	Possessiveness
	Isolation from family/friends/work	Spying
	Made to think they are going mad

Here there is no outward sign of violence/abuse. Many will not believe that the woman has suffered abuse. Women may be subjected to all three types of abuse.

Pregnant women are targets for domestic abuse. A study from Edinburgh 1996 suggests a 1^st pregnancy may be the trigger point for the start or escalation of domestic abuse. Kicking and punching of the abdomen is a common feature of abuse in pregnancy and abused women presenting with such injuries are 3 times more likely to be pregnant than non-abused women presenting with such injuries.

What is the impact of domestic abuse upon health?

WHO has defined health as a state of complete physical, mental and social well-being. The woman who is subject to domestic abuse has no complete physical, mental nor social well-being. She may be physically traumatised – there is no doubt that she is mentally and psychologically traumatised and she is not socially well. Her family also suffer mentally and are socially unwell, living in fear and are often unable to change the situation or help. The whole family may be at risk from abuse. Studies suggest that 50% of children in a family where there is domestic abuse are also at risk.

Physical injury can be ongoing and repeated. Half of the reported victims suffered more than one attack with one third attacked three times or more. The injuries range from scratches & severe bruising, through to attempts to strangle and even death. In the USA it is reported that 4 women die daily from the effects of domestic abuse. A survey in UK in 1996 estimated that nearly 33% of incidents required medical attention and 3% hospital care.

Sexual abuse is directed at the genitalia and range from unwanted advances through to penetration with objects causing damage to the genitalia

A study of women living in refuges reported in 1989 in the American Journal of Nursing attributed noted the following consequences of sexual abuse.

Vaginal Stretching 36%
Infertility 17%
Vaginal bleeding 37%
STD 6.5%
Missed periods 25%

Sexual abuse not only causes severe injuries and complications but also emotional and mental health problems requiring medical help. The real cause of the injuries is rarely reported as abuse.

Psychological abuse can be more powerful than physical attacks and women living with this abuse, suffer similar reactions as do prisoners subjected to brainwashing. It leaves no physical signs of violence but undermines the women’s confidence. Her abuser may traumatise her emotionally and then justify his behaviour with rewards telling her it was for her own good suggesting it was really her fault. This makes it difficult for her to leave him

Psychological and mental health problems occur more frequently among women who have experienced domestic abuse. Their risk of attempted suicide is higher, they are more likely to abuse substances and suffer anxiety and depression.

The Yale Trauma Study in 1991 found that abused women were:

Fifteen times more likely to abuse alcohol
Nine times more likely to abuse drugs
Three times more likely to be diagnosed with depression or psychosis
Five times more likely to attempt suicide

The study also showed that

45% of female alcoholics started out as abused women
25% of all female suicide attempts can be related to domestic abuse

Pregnancy is highlighted as a starting ground for abuse. The abuse here affects two people. Pregnant women are very vulnerable and less able to defend themselves. It has a detrimental affect on the physical and mental health of the mother and on the health and viability of the foetus. Pregnant women may be subjected to the same kind of abuse as other women but unfortunately she receives blows on her abdomen, breasts and genitalia which can injure the foetus. Broken limbs and ruptured organs have been reported in the foetus. Miscarriage, placental rupture, premature birth and low weight babies are a few of the complications. The abused woman is more likely to be late in booking, have sporadic attendance at antenatal clinics and may even state the pregnancy is unwanted. She, too, may fail to report her problem and her partner may ensure this by accompanying her to clinics. It was stated by Browne in 1987 that domestic violence during pregnancy appears to be a risk factor for the eventual homicide of the woman. Pregnant women may also try to appease their distress by abusing tobacco, alcohol and drugs further compromising the health of the foetus.

So serious is this hidden and ignored problem in pregnancy that the Royal College of Obstetrics and Gynaecologists in UK set up a special study group to address this problem and they produced a report "Violence against Women” in 1997 which details the manifestations and sequelae of violence, raises awareness of the size and nature of the problem and lays down guidelines for clinical practice, education, training and research.

In the introduction to the report it was noted by the senior vice-president of this college, John Friend, and his co-editors, Susan Bewley and Gillian Mezey :

That the incidence of violence against pregnant women, for example, is higher and produces more morbidity than any other conditions for which we routinely screen.

What effect has domestic abuse on the children who witness it?

There is fear, great sadness and helplessness

Increased levels of anxiety
Psychosomatic illnesses – headaches, abdominal complaints
Increased tendency to asthma
Low ratings in school and in social competences
May also become abusive

I do not intend to discuss her the reasons why women remain in an abusive relationship as we have heard some of the reasons and research is on going. I wish, however, to go back to the question I posed at the beginning of this paper:

Is domestic abuse condoned, condemned or just ignored in the accident & emergency department, in the hospital clinic, in the consulting room and the ante natal clinic?

For too long health professionals have seen domestic abuse as a social problem and they have given women little support. Many are still unaware of the problem as they have little or no education nor training in the subject. Like the police they do not want to hear or are unwilling to listen too closely to a woman with suspicious injuries, a woman who is anxious and distressed with no real physical cause for her symptoms. Too many professionals are unaware of the existence and effects of sexual and psychological abuse.

In the USA where violence occurs in 25% of homes, health professionals are now slowly responding and old myths are being dispelled – myths such as – it is a private matter – it is caused by drink or drugs – the women themselves are to blame – it occurs infrequently – it only affects certain women.

For many women , health professionals are their first port of call but unfortunately their cry for help is not heard and they are sent back home to their violent partner

A study in an industrialised city of the UK of women who had sought shelter in a place of refuge showed that 80% of these abused women had originally consulted their family physician but only 25% were asked about or had informed their doctor of their domestic abuse and the doctor’s response to this had been far from satisfactory. Women who have been abused want to be asked about their problem and not just prescribed pills and told to go home and forget and forgive. They do want someone to listen, to believe their story, to support and help them and refer them to agencies who can provide help and hope.

Women may present in emergency departments especially with physical injuries. In USA and UK guidelines are now produced in these departments to help health professionals recognise abused patients and ask appropriate questions. A study in USA has shown that where such guidelines or protocols are used there has been an increase in the positive identification of abuse from 5.6% – 30%.

The Royal College of Obstetricians, the British Medical Association and the Royal College of Midwives have all studied the problem, written reports and made recommendations for the identification, support and security of these women and their families and in conclusion I leave these with you now

These overheads summarise the recommendations which if used by all health professionals may not stop the abuse but will recognise, treat, support, inform, facilitate referral & reduce the health impact of abuse. More research is required to give more understanding of the problem – why men abuse- how can we stop it.

Clinical Guidelines

Guidelines should be developed for prevention, detection & management of abuse in the clinical situation. All professional groups should be involved

Health professionals should adopt a non-judgemental and supportive response
Enquiry about a history of violence should be routine in any social history
Routine screening by interview - this is acceptable and welcomed by patients
All clinical departments should display & disseminate information & TEL No of refuges, social services, police, victim support services for staff & abused
Where there is a language barrier - interpreters should be used – not family
Women should have a consultation with the lead professional on her own
There should be a set of confidential notes as well as “hand-held” notes
Accurate & complete documentation of all history & injury – confidential
Sensitive questioning with reassurance of privacy & confidentiality

Education & Training

Postgraduate training and Continuing Medical Education of all health professionals on domestic abuse –
Undergraduate education in domestic abuse should be introduced

Research

An extended & comprehensive research base on domestic abuse
Further research into short & long term health implications of domestic abuse
Specific research into medical practitioners responses to domestic abuse
Research into the relationship between disabilities and domestic abuse.
A central database of domestic abuse research & project should be established